Have you ever wished you could practice medicine in a large, impersonal organization? No? Solo practice, maybe. An efficient group, sure. Large bureaucracy, probably not. From its humble beginnings, family practice has always been about individuals and the personal relationship between doctor and patient. Its roots are undoubtedly solo. Its heroes are solo. Its future is, well, anyone's guess.

When family practice evolved from general practice in the late '60s, solo physicians were the rule, as was fee-for-service care. Solo, independent practice was part of what made family practice so appealing. It represented the rugged individualist who worked hard, knew whole families of patients by name and earned the respect of the community. In 1980, 54 percent of family physicians in direct patient care reported being in solo practice; 14 percent were in two-physician groups (see “The decline of solo practice”). And until 1988, at least 10 percent of family practice residents were choosing solo practice each year.1

The decline of solo practice

In 1980, when fee for service ruled the day and family practice was young, 54 percent of AAFP members in office-based direct patient care practiced solo; another 14 percent practiced in two-physician family practice groups. Over the years, the percentage of family physicians in solo practice has steadily declined to just 25 percent in 1997.

Source: American Academy of Family Physicians. Data are not available for the years between 1980 and 1987.

A lot can change in a decade. In every year since 1988, fewer than 10 percent of family practice residents have gone into solo practice. The percentage of family physicians in solo practice dropped to just 25 percent in 1997, continuing the downward trend. The complexity of today's health care system, especially the threat of managed care, has pushed many family physicians into larger groups, employment arrangements or early retirement and has left many asking whether solo practice still makes sense.

But while many view managed care as the impetus for integration, selling out and getting bigger, others view it as the best incentive ever to stick it out solo. The solo camp questions whether large groups and employed practice can be true to the heritage of the specialty and true to their patients — and whether large organizations can really be effective at all. Douglas Iliff, MD, is a solo family physician who takes this latter view without apology. In our February 1998 issue (see “Solo Practice: The Way of the Future”), Iliff depicted large groups as the mainframe computers of medicine: powerful, impressive-looking machines that will inevitably be rendered obsolete by small, adaptable, efficient solo practices — the equivalent of personal computers in the medical marketplace. Among the merits of solo practice, he pointed to the “bias for action” that comes from the individual's freedom to make speedy, clear decisions, whereas “groups have a bias for argument, posturing, ego gratification, procrastination, blame shifting — anything except action.” He concluded that “the solo practice model of decentralized decision making offers the highest probability for happiness and high profits and that it should be adopted as a structure even in large medical groups, just as cutting-edge companies all over the world have learned to give small cells independent authority to design, build and market their products and services.”

The solo model, though a traditional idea, comes across as radical in today's tumultuous health care environment. The idea of going solo today goes against all the advice of managed care gurus who preach integration above all else. So who's right? What is the role of solo practice in 1998 and beyond? Will managed care make solo practice obsolete? Or is solo practice a legitimate option? More, is it the salvation of family physicians — and their patients?

The flood of reader comments we've received in reaction to Dr. Iliff's article makes us think the solo practice debate is hardly settled in the minds of family physicians. Opinions are of course scattered all along the continuum, but our readers' responses echo one clear theme: A lot of family physicians out there still believe in solo practice in some form. And even those who disagree outright seem to have a special place in their hearts for the model. Here, then, we present a cross section of our readers' comments, in their own words.

I agree wholeheartedly that solo practice is the best way to practice medicine, even today. My solo practice overhead is 45 percent, and I still have the same employees I had 20 years ago. They are all well paid and were fully vested in my retirement plan from day one. The savings of not having staff turnover is significant.

I recently computerized my medical records to address the Medicare documentation problem. Once I found the software I wanted to use, it was just a matter of my deciding how I wanted to computerize the office and how much I wanted to pay. I only had to negotiate with myself and did not have one committee meeting. Probably the greatest advantage of solo practice is that, while we all have to deal with idiots, I don't have any telling me how to do my job. — Douglas Morrell, MD, Rushville, Ind.

I have been in solo family practice in south Florida for more than 20 years, and the managed care penetration is about 50 percent. I submit that if you give great service for a fair price and are available to patients, you will do well. — Robert C. Greer IV, DO, Lake Park, Fla.

My solo practice is thriving too, and I live in an area where managed care penetration is heavy. My overhead runs 28 percent. — Elizabeth B. Lanier, MD, San Luis Obispo, Calif.

I re-entered solo practice four years ago after having been in a group practice. I had doubts about what the future might hold but am happy to relate that it has created more satisfaction for my patients, my staff and myself than I could ever have imagined. A small staff can treat patients as people, not numbers. Overhead is less, income is up and staff turnover is nil. — Stanley F. Peters, MD, Doylestown, Pa.

I wish Dr. Iliff well and hope he can continue his solo practice for many years. Unfortunately it is unlikely to continue as is. I would guess there is very little if any managed care in his community. When he talks of a full practice and not accepting contracts, he is talking of fee for service. This is dead in most parts of the country and will be dying in the remainder.

I was in solo practice for many more years than Iliff and enjoyed them all. Most of his comments are correct; however, it has been said that patient loyalty is a $5 to $10 co-pay, and I'm afraid this is correct. Solo practice cannot persist without a strong group effort behind it, such as an IPA. — Gary H. Schwartz, MD, San Bernardino, Calif.

I have been in solo practice for over 30 years and have carefully observed the changes in medicine, which were tortoise-like until the last decade. Iliff certainly has not witnessed the profound transformation that has occurred over the last three years. Perhaps the marketplace in which he practices is not controlled by HMOs and other payers. I can assure him that in the future he will observe a loss of critical income and a heightened sense of insecurity. I have endeavored to resist these changes in my north Georgia practice and have found myself the victim of this profound transformation. — J.O. Weaver, MD, Cedartown, Ga.

As long as payers are willing to include solo practices in their provider panels, we'll continue to thrive and grow. My patients insist I be approached to sign with any new insurance plans their employers buy, and it works.

I'm the only remaining solo family physician in our town of over 100,000. I don't have any delusions of attracting partners, but I plan to practice solo until I decide to retire. — Duncan L. Hubbard, MD, Missoula, Mont.

How solo practice stacks up

Solo family physicians work more hours per week and more weeks per year than most of their group practice counterparts, but not by much. According to data from the AAFP, soloists work 54 hours per week, 49 weeks per year. Soloists' incomes were beat only by the incomes of physicians in two-person groups.

Dr. Iliff describes the virtues of properly managed solo practices and the success he has experienced in Topeka, Kan., but ignores the value of doctors working together as a group. Certainly the value of any organization must be questioned if it is unable to demonstrate that it can produce superior clinical and service outcomes at a lower cost. But there are numerous examples of success and failure in individual practices as well as group practices and other health care organizations. The “one-size-fits-all” model suggested by Iliff could lead some physicians to strategic and practice management dead ends.

Each physician must develop his or her own strategy based on an assessment of age, skills and local market conditions. The world looks quite different from Topeka than it does from many other markets. The choice must be free but simultaneously must be informed. No model, be it individual or group practice or some other approach, is guaranteed to produce better clinical and patient-service outcomes at a lower cost. The focus therefore must be on the function of the model being considered rather than the form.

Iliff's observation that many of the problems in today's health care industry are due to “system” failures supports the need for a systemic approach. This usually necessitates groups of doctors working toward a common set of objectives. Large numbers of physicians working independently and outside the context of a set of common organizational objectives and without the capital, infrastructure and other resources required to demonstrate superior outcomes will find it difficult to convince an increasingly sophisticated market of their superior performance. But large organizations are no guarantee that performance or accountability will be any better than in solo practice; they only represent the prospect for improvement. That prospect must then be brought to fruition by skilled physician leaders who know how to organize and lead their colleagues through significant change.

Iliff's accomplishment of creating a successful practice on his own terms must be recognized. Simultaneously, the uniqueness of his situation may preclude it from being a model for physicians at different stages of their careers and in different markets. Physicians will need to determine the strategies that best meet their individual needs and how they can best contribute to the overall well-being of their patients. This usually must be done within the context of various “systems,” and as we approach the 21st century, this systems thinking must focus increasingly on the effectiveness of individuals and organizations within the system.— David E. Vogel, MS, Corrales, N.M.

I purchased my solo practice a little over a year ago from a doctor who had practiced in the same building for 43 years. We have a lot of improvements ahead of us, but the important part, the human part, is as strong as can be.

I have been courted by a number of larger groups, which spice their attractive buy-out/buy-in proposals with sage advice that in the next five years solo practice will no longer be a viable option.

What these experts fail to take into account (in addition to the points made in Iliff's article) is the effectiveness of association with other solo physicians to create economies of scale necessary to get the same deals on supplies and other services that the “big boys” get. Remove that benefit, and there are precious few advantages left to the large group.

Solo practice is not for everyone, but neither is group practice. For those of us with strong opinions and a need to act immediately, no other arrangement comes close. — David H. Stern, MD, Torrance, Calif.

Dr. Iliff's article was great to read and confirmed my feelings about solo practice, which I have done since 1986. Ideally, solo family physicians should cross cover with other family physicians. Our area has four board-certified family physicians in solo practice, and we meet each month to discuss issues and call coverage. If everyone is committed to work hard and communicate, this is an unbeatable arrangement with maximal effectiveness and flexibility. — Thomas A. Shapcott, MD, Staunton, Va.

Over the last two years, I've earned the outright dislike of some physician colleagues in my community by being openly critical of those who have irresponsibly taken sweetheart deals by selling out their practices, patients and priorities (for prices ranging from $300,000 to $1.2 million) to one of our local nonprofit hospitals. In the hospital's mad scramble to fulfill its proclaimed mission of establishing an integrated delivery system, it has been on a physician practice buying frenzy over the last year or so — buying not just any practice, but only those practices whose physicians hold key leadership positions in the area. They have sidestepped the law against the corporate practice of medicine by acquiring these prime practices through a for-profit entity wholly owned by the hospital itself. Go figure.

I respect and admire Dr. Iliff's rugged, individualistic approach to the disquieting changes in health care today. Brave physicians with firm convictions, such as Dr. Iliff, offer our profession the greatest hope in preserving what is essential for patient healing. Still, in reading his article, I was left with a vague uneasiness that took some thought and soul searching for me to define. His arguments brought to mind the picture of Nero playing his violin (or whatever they played in those days) while Rome burned.

As paradoxical as it may seem, I see the same general outcome to the integrity of our profession from Iliff's reclusive, passive approach to current changes as that of my self-serving, opportunistic colleagues. While they see change as inevitable, at least they will personally profit from it. Iliff, on the other hand, may have noble convictions and honorable intentions but will share in the responsibility for making our profession less than it should be, and he'll have little to show for it.

I believe our responsibility to our communities and profession goes beyond withdrawing from the battle to remain separate. Now more than ever before, we truly must bear one another's burdens, for in our profession what we do affects us all. — Richard J. Heiss, MD, Bakersfield, Calif.

Solo practice is a way of the future for family physicians, though unlikely to be the only way. Several years ago, I returned to solo practice (having burned out once 15 years ago) so that I could commit a substantial part of my life and energy into voluntary service work.

I would certainly encourage any physician who is not satisfied with his or her current practice, especially if the source of disgruntlement is not simply a financial one, to look at the pluses of solo practice, whether done Dr. Iliff's way or in some other way that works for him or her. The possibilities are immense.

Some of the other physicians in my community have remarked that we have the most hassle-proof practice they have seen. It's true. It is a joy to come to the office each day. Even with the government, the hassles are only momentary glitches on a field of real satisfaction. — Stephen L. Leighton, MD, Winston-Salem, N.C.

Dr. Iliff generalizes too much. The “solo practice model” offers him what he finds satisfying. Some physicians enjoy the entrepreneurial side of medicine and being their own boss. Others would just as soon allow business specialists in a larger group to take care of the day-to-day headaches of small business regulations (taxes, hiring/firing, billing/accounting, retirement investments). A family practice residency should provide residents the opportunity to explore the options available but need not push any one method. — Thomas Babcock, DO, Jefferson, Iowa

Over a year ago, I left an established family practice group that was heavily involved in managed care, dropped out of the local HMO network and started a solo practice. It was a struggle at first. My income initially decreased but is now much higher than before, and my solo practice has blossomed to the point that I will need to expand soon. I am not only enjoying financial rewards but am happier with my career overall. I can make independent decisions without restrictive formularies, authorization requests and other nonsense that treats physicians like children. Is there a more offensive term for a physician than “gatekeeper”?

The conventional thinking among physicians and “experts” is that one will never survive without managed care. That's utter nonsense. The tide will turn against HMOs as the truth about them comes out. If enough doctors would opt out, HMOs would eventually fold under the pressure. They can't survive without us, but unfortunately too many physicians are willing participants.

I believe that with hard work and with attention to quality care and customer service, an independent solo practice will grow quickly, as mine has. Many of my previous HMO patients have switched insurance and are seeing me again, and I am also seeing a lot of patients under point-of-service plans, which are becoming more popular (if I were on the HMO panel, I would not have the option of seeing these patients on a fee-for-service basis as I can now do). I have received a lot of support and respect from patients and colleagues for taking back control of my practice. Ours is a proud profession, and we have in our power the ability to restore that glory to our profession and our lives. — Paul D. Corona, MD, Laguna Hills, Calif.

Practice arrangements of graduating residents

In 1996, the most popular practice arrangements among graduating family practice residents were groups. Family practice groups were undisputedly the first choice, followed by multispecialty groups. Solo practice attracted just under 5 percent of graduating residents.

Source: American Academy of Family Physicians. Report on Survey of 1996 Graduating Family Practice Residents. Reprint 155-V.

Practice arrangement

Percentage of 1996 graduating residents

Family practice group

45.8

Multispecialty group

11.8

Two-physician FP group

8.8

Military

5.8

Hospital staff

5.3

Solo practice

4.5

Further training or fellowship in family practice

4.2

Teaching

2.6

U.S. Public Health Service

2.4

Further training or fellowship in another specialty

1.8

Emergency department

1.8

Other

1.7

Research

0.2

Administrative

0.0

Not specified

3.3

Source: American Academy of Family Physicians. Report on Survey of 1996 Graduating Family Practice Residents. Reprint 155-V.

I am a solo physician and agree with nearly all of Dr. Iliff's points; however, for a physician just ending residency, the start-up capital required to begin a solo practice is usually not financially feasible. For anyone else in solo practice, stay there! HMOs have squeezed all the profit possible from health care premiums. Within five years a return to fee-for-service and point-of-service plans will be the norm; micromanaging medicine by making us call 800 phone numbers will fail due to patient and ultimately employer dissatisfaction.

Dr. Iliff describes a successful, very effectively run, nine-to-five, five-days-a-week solo business. Everything is based on cost-effectiveness. He doesn't assist at surgery (I assume even on his own patients) because it is not cost-effective; he never speaks to a patient on the telephone during office hours (not cost-effective); he makes no mention of following his patients while in a hospital or nursing facility (not cost-effective).

I retired after 40 years of solo practice as a board-certified family physician. I too managed to keep my overhead under 50 percent of my gross but not at the expense of giving up those values that make family practice the wonderful field of medicine that it is. I did talk to distraught patients about their critically ill family members during office hours; I did assist at surgery on my own patients; I did admit and manage my patients when they needed to be in a hospital or nursing home. That is what family practice is all about. Of course I arranged for after-hours coverage with colleagues, but this never created a problem.

Certainly Dr. Iliff has a right to run his practice as he does if this is what he feels it takes to maintain a solo practice in the present environment. But the only thing that seems to be missing from his office is something that one of my less illustrious colleagues had in his office some years ago: a cash register. — Bernard Korn, MD, Beverly Hills, Calif.

Iliff's idea of self-centered individuals doing their own thing and taking care of a devoted clientele shows a lack of dedication and a lack of appreciation for a doctor's life in a small town. The picture he paints is some, but not much, better than selling out. They both mean a detrimental shirking of responsibility (if it's a nuisance, let someone else do it). — Wm. J. Smith, MD, Windsor, Mo.

After 30 years of solo, academic and corporate practice, I agree totally that solo practice is the ideal. But few of us have the business sense to believe it enough to take the plunge. Going solo will never be taught in medical school because those in academia often migrate there after dissatisfaction with their private practices. Besides, the PDR is now 3,000 pages and HCFA lays down new “laws” every year. Young physicians can't do it all — just can't. We need a memorial to fallen physicians' practices. —Joseph Baum, MD, Floyd, Va.

Hurray for Dr. Iliff. What a relief to read his article. I completed my family practice residency in July 1996 and then did a fellowship in rural medicine. Throughout my residency, we heard over and over that HMOs were inevitably the way of the future. I always thought it was only inevitable if we allowed it to happen. I started a solo practice in June 1997 and have been doing just fine. — Leanne L. LeBlanc, MD, Grangeville, Idaho

I have been a solo family physician for the past 25 years working at the same office site since the day I left postgraduate training. On the plus side, solo practice has its greatest strength in offering autonomy and keeping tight control on overhead, yielding greater net income. The reliance I must place on myself to make it work, and work well, gives me great satisfaction.

On the negative side, the advent of managed care means longer hours for myself and key employees who must work harder for the same benefits. Also, when I am absent from the office, the income stream stops yet expenses continue.

I agree with Dr. Iliff's reasons for being in solo practice; however, I think our current environment is steering the next generation of family physicians in the opposite direction. — William A. Kammeyer, MD, Fort Wayne, Ind.

As another successful (enough for me) and happy (most days) solo family physician, I sometimes get the idea that I'm the only one left. While I did not agree with all of Dr. Iliff's practice priorities, I'm glad that as a solo physician I am free to disagree and run my practice in the way that works best for my patients and me. — Max Boone, MD, Athens, Ala.